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OSTATEMENT OF MORTGAGE OR CONT- C 1 DE 3j` •-S County Township Year
FOR DEDUCTION FROM ASSESSED VA .ATY1 ��
State Forth 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCnoNS: SEP 9 2016 File Mark
lb be filed in person or by mail. - Form sled with:
Filing Dates 1) Real Property Must be completed and dated in the calendar ye. For wit. udion is sought
Must be filed or postmarked with the County Auditor or Co 1yy mfy where the property is gl County Auditor
located on or before January 5ofthe immediately ' l )1sly AUDITOR County Recorder
2) Mobile/Manufactured Homes not assessed as Realust file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
nt(owner or con see restrictions on reverse side)
T ' District Key number/legal description _9'
] Read number Page number,
av7 2/0- 7 - d/- 30o 55'x/-Oar e30/ 6) al04`
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage]Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year asseranent data,current year data of application legal or equitable owner?
leo Q 00 ❑ yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
•
If name on record is different than that of appli ant,indicate bebw: Is the property in question:Annually Assessed
y2eal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
. Name of mortgagee or on' seller
Address of mortgagee or contact seller(number and sheet dh state,and ZIP code)
Name of assignee or other owner or holder or mortgage 1r` I (�
Address of assignee(number and sheet dry;state,and ZIP code) I ( —`I Q C t C
•Does applicant own property in any If yes,what county? What Taxing Dislii E r �� sew L aunt of deduction
other county V 111 III J
In Indiana? ❑Yes ❑No "l / l.. ••
A person is not entitled to this deduction unless the person has a balance on the person's nn...,__ l te�')„�� "Tried in the county
recorders office(including any home equity fine of credit that is recorded in the county recorder's office)Thu._ /I ion.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County - Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signal sname)� Date(mo nth,day,year)
rte JO (m— -/
Co
Fug resident address of applicant(number and street dry,state,and ZIP code) '
'')( qcfn 5 100 w QioenSu\\'e1 ouUlksbaS
Person authorized by duly exearted Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
•
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.